E. Schilders MD 2004
Conservative Management in Shoulder Problems
Conservative management of shoulder problems consists of treatment with antiinflammatories, steroid injections, and physiotherapy treatment. It is important to identify the
conditions that qualify for conservative treatment and to identify when surgical treatment
becomes necessary.
The most frequent shoulder conditions GPs are likely to see are:



Capsulitis (frozen shoulder)
Impingement
Instability
How do these conditions differ? Age is usually a good indicator:

Below the age of 35 and presenting with shoulder pain – this is usually an instability
problem.

Above the age of 35 – this is usually impingement although overlapping of both
conditions is possible.
1.
Capsulitis
Patients with capsulitis or so-called frozen shoulder present with active and passive
reduced range of motion in the shoulder. Anterior elevation, internal rotation, and
external rotation are all reduced. Patients present with a stiff and painful shoulder, the
condition has usually had a slow onset and there is also pain at night. Histologically
this condition causes synovitis of the shoulder capsule and fibrous ligamentous
dysplasia. The condition can be primary or secondary.
The most common causes of capsulitis are:

Diabetes – patients who are insulin-dependent diabetic can have a 40% risk of
developing frozen shoulder.

Calcifying tendonitis.

Secondary to rotator cuff pathology and impingement.

Post-surgical.
Primary frozen shoulder

Idiopathic.

Diabetes.

Cerebrovascular infarction.

Cardiovascular infarction.
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E. Schilders MD 2004
Secondary frozen shoulder

Rotator cuff tendinopathy.

Fracture.

Post-surgery.

Post- soft tissue injury.

Arthritis.

Hemiplegia.
A frozen shoulder has three different stages and treatment should be adapted to each
individual stage:
1.
Stage I – the painful phase. This stage usually lasts weeks to months. Patients
complain of generalised and anterior shoulder pain. They also complain of pain
when the arm is at rest. Inflammatory symptoms dominate this stage.
2.
Stage II – the stiffening phase. This stage usually lasts 4 to 12 months. The
pain gradually settles down and patients do not complain of anterior shoulder
pain when the arm is at rest during the day, although they may still complain
of pain at night. Stiffness dominates this stage.
3.
Stage III – the thawing phase. This stage usually lasts months. Patients
gradually return to a normal range of motion.
Treatment
Treatment of capsulitis may consist of conservative or surgical management.
Conservative management consists of rehabilitation with a stretching programme or an
intra-articular steroid injection. Surgical treatment consists of an open or arthroscopic
capsular release (excision of the rotator cuff interval, or excision of the coracohumeral ligament). The third option is MUA (joint manipulation under anesthesia)
usually combined with an intra-articular steroid injection. Surgical treatment is seldom
necessary unless the pain and stiffness prove to be resistant to conservative treatment.
I personally do not favour the option of MUA because of the potential of iatrogenic
capsule tears (labral tears) and even rotator cuff tears.
Timing is a very important factor in conservative management. During the painful
phase aggressive stretching should be avoided, as this will induce an increase of the
synovitis and the potential of increased pain and further reduction in mobility. In this
stage pain-free stretching is indicated and it is useful to associate an intra-articular
steroid injection. Once a patient’s capsulitis has progressed to stage II stretching can
be more aggressive and strengthening exercises can also be increased.
To improve mobility and scapulo-thoracic rhythm McConnell taping can also be very
helpful. Usually this is applied twice a week for 24 hours and it improves
proprioception.
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E. Schilders MD 2004
2.
Impingement
Impingement of the rotator cuff occurs below the coraco-acromial ligament, the
acromion and the acromio-clavicular joint. This type of impingement is referred to as
external impingement as opposed to internal impingement, which will be discussed
under the section “Instability”. Impingement usually causes lateral shoulder pain and
pain at night.
Ultrasound scanning of the rotator cuff helps us to determine which patients are
suitable for conservative or surgical treatment:

Patients who do not have any severe degenerative changes or tears of the rotator cuff
are ideal for a subacromial injection.

Patients with severe degeneration of the rotator cuff are usually ideal for subacromial
decompression.

Patients with small or large rotator cuff tears are candidates for rotator cuff repair.
Very often impingement is associated with degenerative AC arthritis, more
particularly so in patients over the age of 45.
Osteolytic-type AC arthritis in isolation is seen more frequently in younger patients
who lift weights.
Treatment
Conservative treatment consists of steroid injections with local anaesthetic
combined with a physiotherapy programme consisting of rotator cuff
strengthening exercises. Injections are administered into the subacromial space from
the lateral or posterior part of the shoulder. The injections can also be administered
under ultrasound guidance.
3.
Calcifying Tendinitis
Calcifying tendonitis refers to the presence of calcium deposits in the rotator cuff
tendons (usually the supraspinatus). Patients with this condition can present acutely
or with a gradual onset. Very often the acute presentation is similar to stage I of
capsulitis and patients present with severe shoulder pain. The typical profile for this
condition is a 45-year old female. This condition can be easily identified on plain xrays.
Treatment
Conservative treatment is similar to that for the inflammatory stage of capsulitis and
consists of a gentle stretching programme, anti-inflammatories and a subacromial
injection. Needling of the calcification can be performed under ultrasound guidance
and extracorporeal shockwave therapy may also be performed. It is important to take
repeat x-rays if a patient remains symptomatic as the calcification may increase.
Equally so, it can also disappear.
Patients with persistent symptoms require arthroscopic needling of the calcification.
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E. Schilders MD 2004
4.
Instability
There are four main types of instability that are suitable for conservative treatment:

Multi-directional instability - The most pathognomonic sign of this condition is the
Sulcus sign. This condition is usually found in the younger age group, although
overlapping with impingement is possible above the age of 35. A typical symptom of
this condition can also be Dead Arm Syndrome.

Anterior instability in the throwing athlete - Stretching of the anterior capsule (anterior
band of the inferior glenohumeral ligament) occurs as a result of repetitive overhead
throwing activities. Increased external rotation compared with the patient’s opposite
shoulder typically occurs with this condition. Patients complain of posterior shoulder
pain, which occurs as a result of the internal impingement of the rotator cuff.

Traumatic anterior instability - Patients dislocate or sublux their shoulder usually as a
result of an abduction/external rotation injury. The younger age group (below 27) and
sports-active patients usually qualify for surgery due to a higher risk of recurrence of
dislocation. Subluxers usually respond better to conservative treatment.

Voluntary dislocators – this group is smaller and can very often be difficult to treat
given that this condition can involve a large psychological component. In this
instance surgery is best avoided.
Treatment
Conservative treatment consists of an aggressive strengthening programme usually
directed at the four groups of muscles easily remembered as the Four P’s:

P1 –
The glenohumeral protectors - Supraspinatus, Subscapularis, Infraspinatus
and Teres Minor.

P2 –
The scapular pivotors - Serratus Anterior, Trapezius, Rhomboids, and
Levator Scapular.

P3 –
The humeral positioner - the Deltoid.

P4 –
The power drivers - Latisimus Dorsi and Pectoralis Major.
In throwing athletes it is important to add posterior capsular stretches to the
strengthening programme.
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